Shoulder, Clavicle, Brachial Disorders COPY Flashcards
What muscles make up the rotator cuff? 4
What bones are involved in the rotator cuff? 5
What are the bones of the shoulder? 5
Joints? 4
- Scapula 1. SC joint
- Humerus 2. AC joint
- Clavicle 3. Glenohumeral Joint
- Sternum 4. Scapular thoracic
- Ribs
What are the muscles of the shoulders?
10
Muscles of the Shoulder
Rotator cuff,
- Supraspinatus,
- Infraspinatus,
- Subscapulars,
- Teres Minor
- Pec Major
- Biceps, long head and short head
- Deltoid
- Trapezius
- Serratus anterior
- Rhomboid
Name 6 shoulder conditions in the lecture?
- Traumatic
- Over use
- Instability
- Fractures
- Age related processes
- Nerve injuries
What is an AC separation typically a result of?
2
Typically as a result of
- falling directly on the tip of the shoulder or
- hockey player getting checked into the boards
AC Separation
- Disruption of which ligaments? 2
- Describe Grades 1-3 separations
- Disruption of the
- Coracoclavicular ligaments and
- Acromioclavicular ligament
AC Separation Clinical Findings
6
- Tenderness at the AC joint
- Possible deformity at the AC joint
- Pain with adduction of the shoulder
- +Cross arm test
- +Paxinos test with anterior and posterior instability
- Pain with doing a dip
Whats paxinos test?
Anterior and Posterior Instability
AC Separation Treatment
- Treated with? 2
- What do we do if pain is persisting depsite conservation management?
1.
- Rest, Ice, NSAIDs
- Sling for comfort for a week or two
2. Weaver-Dunn procedure if pain is persisting despite conservative management. - Reconstruction of CC ligament
Rarely treated with surgery
Return to play and activity is determined on patients comfort level
Clavicle Fracture
How is the mechanism of injury different from an AC joint injury?
Similar mechanism of injury as an AC joint separation only the energy passes through the bone causing a fracture
Rarely treated with surgery although becoming more common to fix
Clavicle Fracture Clinical Findings
4
- Tenderness to palpation over the fracture site of the clavicle.
- Pain with adduction of the shoulder
- Patient will be sitting with shoulders rolled forward
- Deformity at fracture site possible tenting of the skin
Clavicle Fracture Treatment
4
- Rest, Ice, NSAIDs,
- Sling for comfort, possible figure 8
- Return to activity is roughly 8 weeks
- Surgery if significant displacment
Rotator Cuff Tendonitis
- What kind of injury?
- In who? 2
- Often the result of?
- Accompanied in what? 3
- Overuse injury
- typically occurring in throwers in athetes but more common in adults in 4th 5th decades of life
- Often the result of inability to train appropriately during the off season for athletes, weekend warriors
4.
- Inflammation of cuff tendon,
- degenerative fraying,
- bursitis
Rotator Cuff Tendonitis Clinical Presentation
5
- Development of pain after an aggravating activity such as painting the house
- Pain can be insidious without specific injury
- Localized to the anterior lateral aspect of the shoulder
- Pain is worse with reaching overhead or behind the body
- Pain at night difficult to sleep
Rotator Cuff Tendonitis Clinical Exam
6
- Tenderness to palpation over the greater tuberosity or bicepital groove
- Painful arc of motion and elevation
- Full range of motion
- Pain with resisted supraspinatus testing
- Hawkins, + Neers Impingement sign
- No need for MRI unless refractory to treatment
No weakness on exam
Rotator Cuff Tendonitis Clinical Exam: Hawkins Impingement Sign
Rotator Cuff Tendonitis Treatment
4
- Treated aggressively with rest in throwers, “6 weeks of rest”
- Graduated throwing program
- Physical Therapy for Rotator cuff strengthening
- Subacromial Steroid Injection
What muscle is this?
Supraspinatus
What is this strengthening?
Infra/Teres Strengthening
What is this strengthening?
Subscapularis Strengthening
- Rotator Cuff tear is most commonly what kind of process?
- With tears occuring as a result of what?
- What are the most commonly torn rotator cuff tendons? 2
- What is more commonly torn as a result of trauma?
- Rotator cuff tear very uncommon prior to the age of what?
- Risk factors for cuff tear? 3
- Rotator cuff tear is most commonly a degenerative processes with
- tears occurring as a result of breakdown of the tendon and eventual wearing out
- Supraspinatus and Infraspinatus most commonly torn rotator cuff tendon
- Subscapularis more commonly torn as a result of trauma
- Rotator cuff tear very uncommon prior to the age of 30
- Risk factors for cuff tear:
- Age,
- smoking,
- fall
Rotator Cuff Tear Clinical Presentation
- Presents similar to what?
- Presents how? 4
- Pain radiates to where?
- Onset?
- May tell you they felt what at the time of injury?
- Rotator cuff tear presentation is similar to rotator cuff tendonitis
2.
- Pain with reaching overhead,
- night pain, cannot get comfortable lying on shoulder,
- weakness,
- pain over the anterior lateral aspect of the shoulder.
3. Pain radiates to the deltoid insertion
4. Pain can be insidious or as a result of trauma such as a fall or lifting something
5. May have felt a pop at the time of the injury
Rotator Cuff Tear Clinical Exam
- Similar exam to tendonitis with exception of what?
- What kind of issues with range of motion?
- Weakness in External Rotation = __________ tear
- Weakness with Empty Can = ___________ tear
- Weakness with Internal Rotation = _________ tear
- Xray findings?
- weakness of affected rotator cuff
- Full passive range of motion but limited active ROM
- Infraspinatus
- Supraspinatus
- Subscapularis
- X-ray will have subtle findings but most of the time negative
Rotator Cuff Tear Clinical Exam
Special Tests?
4
- Bear Hugger test = Subscapularis
- Lift off test = Subsapularis
- Belly Compression test = Subscapularis
- Hawkins, + Neers
Rotator Cuff Tear Treatment
5
- Rest, Ice, NSAIDs
- Physical Therapy for rotator cuff strength program
- Subacromial steroid injection
- MRI to evaluate size of rotator cuff tear or rule it in
- Surgical repair of the rotator cuff
- Calcific Tendonitis: What is it?
- Most common?
- Describe its consistancy? and the different phases in which pain and inflammation changes? 2
- Deposition of calcium “hydroxyapatite” the rotator cuff tendon.
- Supraspinatus most common
3.
- Different consistency of calcium deposit.
- During liquid/tooth paste phase more painful and inflammatory
- Chalk consistency more dormant and no inflammation.
Calcific Tendonitis Clinical Presentation
- Onset?
- Pain with what? 2
- Can be insidious in onset or sudden development of severe “white knuckle pain”
- Pain with any movement of the shoulder and Unable to sleep due to pain
Calcific Tendonitis Clinical Exam
5
- Tenderness over the greater tuberosity
- Limited Active range of motion seconday to pain.
- Pain with firing the rotator cuff
- Full passive range of motion and not as painful as active motion
- Weakness of cuff due to the pain only, no true weaknesss
Calcific Tendonitis tx
4
- NSAIDS, Ice, Rest
- Physical therapy to prevent stiffness but not typically helpful
- Subacromial steroid injection with Needling of calcium deposit
- Surgical decompression and debridement of calcium deposit
Adhesive Capsulitis
- Frozen Shoulder is what?
- May follow what?
- Risk factors? 3
- Cause?
- Three phases?
- Frozen shoulder is a loss of motion of the shoulder as a result of tightening and shrinking of the shoulder capsule
- May follow a trauma to the shoulder
- Risk factors:
- Female,
- Diabetic,
- Hypothyroidism - Idiopathic
- Three Phases: Freezing, Frozen, Thawing, can take as long as 2 years
Adhesive Capsulitis Clincal Presentation
5
- Insidious onset of pain and progressive loss of motion
- May follow a trauma but normally idiopathic
- Pain at end range of motion
- Night pain
- Can’t reach into back pocket
Adhesive Capsulitis Clincal Exam
2
- Loss of both Passive and Active range of motion
- Pain at end range of motion
Adhesive Capsulitis Treatment
4
- Physical Therapy to work on capsular stretching
- Glenohumeral steroid injection in early stages to decrease inflammation of the capsule
- Manipulation under anesthesia “tear adhesions and capsule”
- Arthroscopic capsular release
- Labral Injuries are common in who?
- Injury to what?
- What does SLAP mean?
- Common in throwers as an overuse injury or traumatic in football, wrestling, volleyball, tennis.
- Injury to the soft tissue cartilage ring around the socket of the shoulder which provides stability to the shoulder
- SLAP: Superior labral, anterior-posterior
Labral Tear Clinical Presentation
- Common complaint is what?
- Difficulty with what?
- Mild sense of what?
- Common complaint is a ‘painful pop’ in the shoulder
- Difficulty throwing a ball
- Some mild sense of instability
Labral Tear Clinical Exam
3
- Full range of motion,
- crepitus with internal and external rotation
- Obrien test = SLAP tear
Labral Tear Treatment
3
- Treatment is conservative with no significant time off needed from sports
- Physical Therapy for rotator cuff strength and stabilization
- If pain is persisting despite conservative measures then surgical repair
Impingement problems
- Posterior impingement common in throwers due to what?
- Most will complain of pain where?
- Treated with?
- increased laxity to the anterior shoulder capsule during cocking phase of throwing and tightness in the back
- in the back of the shoulder worse while throwing.
- Treated with aggressive stretching program for the anterior capsule of the shoulder and strength program for the rotator cuff
Posterior Impingement
- Overstretching occurs in what phase of throwing?
- Pain and impingement occur in which phases? 2
- Over stretch of the anterior capsule in the cocking phase
- Pain and impingement occurs in the acceleration and deceleration phase
Shoulder Dislocation
- Occurs most often due to what?
- Which dislocation is more common?
- to elevation and external rotation of the shoulder
- Anterior dislocation much more common than posterior dislocation
Posterior dislocation more common in who?
Can also result from what? 2
- football lineman due to blocking position.
- Also as a result to seizure and electricution
Anterior Dislocation Clinical Presentation
5
- Pain following an injury.
- Felt a pop and sensation of dislocation with significant pain.
- May stay out and need to be reduced or self reduces.
- First time dislocation is treated with reduction of the dislocation and early immobilization
- Physical Therapy to work on shoulder stabilization with rotator cuff strengthening
Anterior Dislocation Clinical Exam
4
- Positive Apprehension sign
- Positive Relocation test
- Increased anterior translation
- Pain with range of motion and guarding with reaching overhead
Anterior dislocation Tx?
6
- X-ray to r/o anterior/inferior glenoid fracture “Bony Bankart”
- X-ray Hillsachs deformity
- Physical therapy to work on cuff strength and stabilization
- Return to play roughly 4-6 weeks and may require bracing to prevent re-dislocation
- Recurrent dislocations will require surgery
- MRI of shoulder if 50 years or older to r/o rotator cuff tear
Posterior Dislocation is treated how?
4
- Treated conservatively with reduction and immobilization
- Physical Therapy to work on rotator cuff strength exercises
- Bracing may help with prevention
- Recurrent dislocation require surgery to stabilize
Describe the injury of posterior location and how it happens?
Most commonly seen when? 1
(can also be seen)
- The shoulder will get forced out the back by getting struck in the shoulder or by blocking an immovable object
2.
- Most common in lineman due to blocking or being blocked
- (Motor vehicle accident, seizure or electrocution)
Shoulder Multidirectional Instability
Most common in which type of athletes? 2
Wrestlers and volleyball players are the worst offenders
Shoulder Instability Presentation
3
- May have multi-joint laxity
- Report recurrent shoulder dislocation but have never had to go to the ER to have the shoulder reduced.
- Will also complain of a dull ache in the shoulder
Shoulder Instability Treatment
2
- Treated with aggressive physical therapy to strengthen scapular stabilizers as well as rotator cuff
- Surgical intervention is last treatment option
Glenohumeral Osteoarthritis
- Why is this a less common spot for OA?
- Risk for OA of the shoulder includes? 4
- Osteoarthritis of the shoulder less common than knee or hip OA, due to the fact the shoulder is non weight bearing
2.
- previous trauma such as dislocation,
- instability issues,
- hereditary,
- heavy laborer
Glenohumeral Osteoarthritis Clinical Presentation
4
- Insidious onset of shoulder pain located anterior lateral or posterior.
- Pain typically achy with sharp overtones
- Loss of range of motion, may not be obvious to patient
- Pain at end range of motion with sudden movement
Glenohumeral Osteoarthritis Clinical Exam
4
- Loss of range of motion especially external rotation and internal rotation
- Strength will be normal
- Crepitus with range of motion of glenohumeral joint “cogwheeling”
- Tender over the anterior and posterior capsule of the shoulder
Glenohumeral Osteoarthritis Treatment
6
- NSAIDs, Tylenol
- Terminal stretching to prevent further stiffness
- Glucosamine/Chondrotin
- Activity modification
- Glenohumeral steroid injection
- Total shoulder replacement
Parsonage Turner Syndrome
- Brachial plexus neuritis or neuralgic amyotrophy, is a condition characterized by what? 2
- Describe the progress of this syndrome?
1.
- inflammation of a network of nerves that innervate the muscles of the chest, shoulders, and arms.
- “Suprascapular nerve”
2. Although individuals with the condition may experience paralysis of the affected areas for months or, in some cases, years, recovery is usually eventually complete
Parsonage-Turner Syndrome Clinical Presentation
2
Individuals with the condition first experience
- severe pain across the shoulder and upper arm.
- Within a few hours or days, weakness, wasting (atrophy), and paralysis may affect the muscles of the shoulder
Parsonage-Turner Syndrome Clinical Exam
4
- Atrophy of the supra and infraspinatus muscles
- Significant weakness of the affected muscles
- Usually non tender
- If in the acute phase, patient may not tolerated palpation and are in extreme pain
Parsonage-Turner Syndrome Treatment
5
- EMG studies or MRI may be helpful and excluding cervical radiculopathy, rotator cuff tear
- Oral cortical steroids
- Neurontin
- Pain medication
- Physical Therapy
Supraspinatus Exercises
1
- Empty can exercises with thumb down
Can be performed with light dumbbells or rubber tubing
Infra and Teres Minor Exercises
Cable or rubber tubing exercises
With the elbow at the side the arm externally rotates against resistance
Subscapularis Exercises
What are these strecthing? 2
Anterior capsule stretch and subscapularis
What is this strecthing? 3
- Posterior capsule ,
- infraspinatus,
- teres minor stretch
What is this strecthing?
Sleeper stretch for posterior capsule tightness and loss of internal rotation
